Ferdnand C. Osuagwu

Celery root extract as an inducer of mania induction in a patient on venlafaxine and St John's Wort.

ABSTRACT Celery root belongs to a group of plants classified as the umbelliferous family, which contains phytoestrogens. Phytoestrogens are structurally similar to estrogen as they share a pair of hydroxyl groups and phenolic ring, which enables them to bind to estrogen receptors directly, making them a herbal remedy for low estrogen states such as menopause. We present a case of a female patient with depression who was stabilized on venlafaxine and St John’s Wort, and who developed a manic episode due to elevated serum venlafaxine levels after she started taking celery extracts for menopausal related issues. We proffer a hypothesis for this unusual occurrence.

Evaluation of the Body Parts That Preoccupy Adolescents With Body Dysmorphic Disorder

Objective To evaluate which body parts preoccupy adolescents with body dysmorphic disorder (BDD). Methods Patients admitted to an inpatient psychiatric hospital who agreed to take part in the study completed the Body Dysmorphic Disorder Questionnaire (child and adolescent version) and Body Dysmorphic Disorder Diagnostic Module. Patients also completed a questionnaire that addressed age at onset, coping strategies, history of sexual abuse, amount of time patients spent thinking about their perceived defects, and the area of the body that the participants were preoccupied with and the specific coping strategy used. All patients met DSM-5 criteria for BDD. The study was conducted from January 17, 2014, to September 29, 2014. Results Patients with BDD (N = 17) were preoccupied with the face: 6 (35.2%), skin: 3 (17.6%), lips: 5 (29.4%), nose: 3 (17.6%), teeth: 3 (17.6%), ears: 1 (5.8%), and eyes: 1 (5.8%), while gender-specific parts included breasts: 5 (50%) and penis: 4 (57.1%). The mean age at onset of BDD was 10.5 years, and the time spent thinking about the imagined defect averaged 3.5 hours per day. Conclusions Patients with BDD are more preoccupied with exposed facial body parts such as skin, lips, nose, teeth, ears, and eyes and body parts with sexual connotations such as breasts in females and the penis in males.

Use of Topiramate in Skin-Picking Disorder: A Pilot Study

Objective Repetitive skin picking that culminates in skin lesions and excoriations has a fairly common prevalence and causes clinically significant distress. Myriads of agents have been used to treat the condition with no convincing results. Methods Ten patients (8 women and 2 men) with skin-picking disorder (per DSM-5 criteria) were enrolled in the study. The study was conducted from December 1, 2013, to December 29, 2014. The patients were treated with 12-week open-label topiramate in a titrating-upward dose (25-200 mg/d). Different measures to evaluate the efficacy of topiramate included subjective and objective assessment, photographs, the Skin Picking Scale modified after the Yale-Brown Obsessive-Compulsive Scale (SPS-Y-BOCS), the Skin Picking Impact Scale, the Clinical Global Impressions-Improvement (CGI-I) and CGI-Severity scales, and the Beck Anxiety Inventory and Beck Depression Inventory. Results Topiramate improved time spent skin picking from 85 minutes to 30 minutes per day. Seven patients (70%) were very much improved (n = 4) and much improved (n = 30) on the CGI-I. The scores on the Skin Picking Impact Scale and SPS-Y-BOCS also improved. The mean time to respond to topiramate was about 8 to 10 weeks. Anxiety and depression symptoms improved after reduction in skin-picking symptoms (the Beck Anxiety Inventory score improved from a mean of 38.8 to 13.8 and the Beck Depression Inventory score from 28.9 to 10.1). Conclusions Topiramate appears to be a promising agent in the treatment of skin-picking symptoms. Double-blind controlled trials are needed to further evaluate the safety and efficacy of topiramate in larger population samples. Trial Registration ISRCTN registry identifier: ISRCTN15791118.

Clopidogrel-Induced Auditory and Visual Hallucinations

To the Editor: Clopidogrel is a thienopyridine derivative used for prevention of thrombotic events. We report a case of clopidogrel-induced auditory and visual hallucinations.

Trimethoprim-Sulfamethoxazole–Induced Psychosis Culminating in Catastrophic Self-Injury: A Case Report

To the Editor: Although trimethoprim-sulfamethoxazole (TMP-SMX) seldom causes psychosis, the side effect of visual and auditory hallucinations has been described previously, principally among immunocompromised persons and elderly patients.1 We are aware of only a single case report of psychosis in an immunologically competent teen2 and of no suicides or attempts attributed to TMP-SMX. Here, we report a case of catastrophic self-injury resulting from TMP-SMX–induced psychosis. Case report. An 18-year-old white, male, high-school senior was admitted to the hospital in January 2015 for a self-inflicted gunshot to the face. Seven days before admission, the patient initiated a course of TMP-SMX for an infected toenail. He began to feel depressed and moody and withdrew to his room. His family said he appeared agitated and was uncharacteristically rude. On the day of admission, the patient “saw” his deceased paternal uncle, himself a victim of suicide. The vision audibly reassured him, “It is okay to shoot yourself.” Shortly afterward, the patient did so, leaving a photograph of his uncle on the floor nearby. He denied past psychiatric treatment but recalled experiencing mood changes and hallucinations when treated with TMP-SMX 8 months earlier. To minimize psychiatric symptoms, he had taken the medication every other day rather than as prescribed. Medical and substance use history was insignificant. Family history was noteworthy for suicide in a paternal uncle and possible depression in the father. At admission, the patient displayed extensive facial injuries. His mandible was missing and a gaping cavity assuming the dimensions of a large pear or small gourd replaced his nose, mouth, and much of the maxilla. The narrow part of the wound created a wide chasm separating the laterally displaced though still functional eyes. He was conscious and had limited capacity to communicate. Results from the urine toxicology screen were negative, and electrolytes were within normal limits. The computerized tomography scan showed extensive facial fractures, a small anterior subdural bleed to the left of the falx cerebri, a left inferior frontal gyrus contusion, and punctate air pockets in the left inferior frontal fossa. TMP-SMX was discontinued while critical care and surgical teams stabilized the patient. The brain lesions did not require neurosurgical intervention. On the 10th hospital day, the patient could be interviewed; he denied, through nods and hand signals, that he had experienced any symptoms of depression or psychosis since coming to the hospital. He was lucid and as cheerful as one could hope under the circumstances. The diagnosis of TMP-SMX–induced psychotic disorder (DSM-5) was made on the basis of hallucinations, which developed during both of 2 courses of treatment with TMP-SMX, a drug that can cause these symptoms. The condition is not explained by the presence of another psychotic disorder, reveals no evidence of delirium, and caused extreme distress and impairment. The patient and his family were referred for counseling to aid their adjustment to the new circumstances. The mechanism for TMP-SMX psychosis is unknown. Both component drugs inhibit metabolism of folic acid, deficiencies of which have long been associated with neuropsychiatric symptoms. Trimethoprim irreversibly inhibits dihydrofolate reductase (DHFR), thereby limiting the conversion of dihydrofolate to tetrahydrofolate, the active form of folic acid. DHFR is also critical for reducing dihydrobiopterin to tetrahydrobiopterin (BH4) in a BH4 salvage pathway. Deficiency of BH4, a cofactor in the biosynthesis of the biogenic amines,3 has been linked to schizophrenia.4 This case highlights the importance of alerting patients about a rare TMP-SMX side effect. Although the mechanism of toxicity is unknown, putative impairments in folate- and biopterin-synthetic pathways warrant further research.